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MEMBERSHIP APPLICATION PAGE 2 OF 2 PARENT / GUARDIAN CONSENT HEALTH HISTORY ALLERGIES DISEASES MEDICAL RELEASE This health history is correct so far as I know and the person herein described has permission to engage in all prescribed Club activities except as noted by the examining physician and me. I hereby give permission to the physician selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named on this application. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. HOLD HARMLESS CLAUSE I further agree that the Boys & Girls Clubs of the San Gorgonio Pass, it’s Board of Directors, officers, staff and volunteers are hereby relieved of any and all liability, including but not limited to medical treatment, emergency transport or on-site assistance, in the event of accident or injury to the said minor. OPEN DOOR POLICY – DOES NOT APPLY TO SCHOOL SITES WHEN SCHOOL IS IN SESSION I understand the Boys & Girls Clubs of the San Gorgonio Pass has an “Open Door” policy that allows Club members to enter and leave the Clubhouse facilities as they choose. I understand that other adjacent areas outside the Clubhouse may not be supervised by the Boys & Girls Club staff, and because of the “Open Door” policy, my role as a parent determines where my child can play. Therefore, I agree that the Boys & Girls Club is not responsible for my child if they leave the Clubhouse premises. Also, I understand the Boys & Girls Clubs of the San Gorgonio Pass is not a licensed day care provider by its’ own choice. PUBLICITY RELEASE I hereby consent to authorize the reproduction, publication and use the Boys & Girls Clubs of the San Gorgonio Pass and Boys & Girls Clubs of America, and their successors and assigns, for advertising, commercial, or any other purposes of any photograph picture or likeness of my child. EXCHANGE OF CONFIDENTIAL INFORMATION I give permission for the release and exchange of confidential information from the following sources in order to provide programs and coordinate services for my child. This information is for the express use of the Boys & Girls Clubs of the San Gorgonio Pass and will not be shared with any other organizations or businesses. (Sources: Banning Unified School District and Beaumont Unified School District) CONSENT I have read and understand the above and hereby give my permission for my child to become a member of the Boys & Girls Clubs and to have my permission to participate in all the activities/programs offered by the Boys & Girls Clubs. I understand that my child must have good behavior and the Boys & Girls Club is a private organization and membership is a privilege and my be revoked at anytime. Additionally, I understand that the Boys & Girls Clubs is not responsible for the time or manner in which my child may arrive at or leave the Clubhouse, and that the Boys & Girls Club and its property are not responsible for personal injury or loss of property. HANDBOOK I have received and reviewed the Handbook for Members & Parents. Parent / Guardian signature: ____________________________________ Date: ___________________ Chicken Pox Measles German measles Mumps Asthma Ivy Poisoning Hay Fever Insect Stings Penicillin Other Drugs Frequent Ear Infections Heart Defect/Disease Convulsions Diabetes Bleeding/Clotting Disorders Contact us at: (951) 922-3259 fax: (951) 922-2141 www.bgcsgpass.comwww.bgcsgpass.com admin@bgcsgpass.comadmin@bgcsgpass.com PO Box 655, Beaumont, CA 92223

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